New Member Application

* I Confirm the Following:

I am completing this form as a registered Healthcare Professional.

Consent to Process Personal Information

The society uses Your Personal data to process your membership application. By using the Service, You agree to the collection and use of information in accordance with the AAMSSA Privacy Policy and the Terms and Conditions.

* POPIA:

I understand the purpose for disclosing this personal information. Collection of this information complies with The Protection of Personal Information Act 4 of 2013 (POPI), South Africa.

* Privacy Policy:

I accept the AAMSSA Privacy Policy and the Terms & Conditions.

* Title

* First Name

* Last Name

* HPCSA MP Number Please start with MP-.....

* ID Number

* Mobile

Practice Name

* Main Practice Address

Area

Practice Located In

* Please specify:

Country

Please specify:

* Telephone number to show to public:

* Profession MBChB - HPCSA Registered Professionals Only

* Please specify:

* Email

* Confirm Email

* Username

Website

Preferred Email for Communication

* Consent to join the AAMSSA WhatsApp Group:

Cellphone number for the WhatsApp Group is:

Alternative Practice Address

Alternative Practice Tel

Special Practice or Procedure Interest(s)

Procedure History:

Please indicate the average amount of procedures performed per month for the following:

* Botulinum Toxin Injections

* Dermal Fillers

* Chemical Peels

* Mesotherapy

* Sclerotherapy

* Skin Rejuvenation

* Anti-Aging Consultations

* Aesthetic Surgery Procedures

* Slimming / Weight Loss

Other/ Specify

Aesthetic and Anti-Aging Medicine Trainings Attended in the past 24 months:

Training 1 Completed

Date Completed

Congress, Course, Workshop or Diploma Name

Institution / Company

CPD Points Received

Training 2 Completed

Date Completed

Institution / Company

Congress, Course, Workshop or Diploma Name

CPD Points Received

Training 3 Completed

Date Completed

Institution / Company

Congress, Course, Workshop or Diploma Name

CPD Points Received

* Are there any Malpractice / HPCSA cases against you?

No

Yes

If Yes, Provide Details:

Upload your Abbreviated CV

Upload

Upload your HPCSA Medical Practitioners Registration Certificate

Upload

Upload your Aesthetic and Anti-Aging Training Certificates (locally or internationally)

Upload

Additional Supporting Document

Upload

Additional Supporting Document

Upload

Additional Supporting Document

Upload

Additional Supporting Document

Upload

* Password

* Confirm Password

* Consent to Upload Profile Picture in Find a Doctor Section:

I hereby give my consent to AAMSSA to upload my profile picture provided by me to upload in the Find a Doctor section. I may exercise my right to withdraw the use of my profile picture anytime after from the effectivity of this consent.

Yes, please show my profile on Find A Doctor search

* Information Verification

I confirm that the above information that has been captured by myself is true and correct at the time of submitting this application

New Member Application

Please Note: We can only accept membership applications from qualified medical doctors. (Minimum requirements: MBChB)

Consent to Process Personal Information

Procedure History:

Aesthetic and Anti-Aging Medicine Trainings Attended in the past 24 months:

Please Note: We can only accept membership applications from qualified medical doctors.
(Minimum requirements: MBChB)